Few public health practices are as controversial as syringe exchange programs, which allow people who inject drugs to exchange used hypodermic needles for sterile ones. Supporters of syringe exchange laud the programs as proven methods of disease reduction and sound public policy. Opponents shudder at the mention of the words, like suggesting heroin as a teething ointment for babies. Never mind that syringe exchange programs have been proven to reduce HIV and hepatitis C rates among injection drug users by as much as 80 percent and 50 percent, respectively. Never mind that they've saved millions in public funding for disease treatment (it costs about $380,000 to treat a person with Medicaid for HIV and $280,000 for a liver transplant for someone with hepatitis C). Never mind that research has shown no increase in drug use with the presence of syringe exchange programs. This is about morals, folks. And drug users are...err...bad people.

As fact-averse as arguments against these programs may be, the reality is that much of the country still regards syringe exchanges as dark places teeming with junkies who suck the soul out of good folks who've never done drugs (except for Percocet, OxyContin, and Vicodin, but those are pimped by dealers in white coats). It's hard to argue cost-savings and disease reduction to a moralistic audience, and in many parts of the country, it's no use even trying (I'm looking at you, Southern states). Change will come, eventually. Even the places where syringe exchange is now state-funded were resistant at first. But for the time being, some states might want to steer clear of that-which-must-not-be-named and consider alternative means to syringe access and disease reduction, such as changes in syringe Acquisition, Enforcement, and Disposal.

Acquisition: Where and how people acquire syringes is an important area of consideration for disease reduction. In the absence of syringe exchange, many people get needles from the internet or from their local pharmacy. But in 24 states, pharmacists are restricted from selling syringes to injection drug users or people who "look like drug users." Naturally, discretion leads to discriminate sales, with many people denied syringes based on such arbitrary factors as race, clothing, health, and other aspects of appearance. A study out of the Research Triangle Institute in North Carolina reported that people of color were one fifth less likely to get syringes from pharmacies than their white counterparts, leading to a higher risk of exposure to HIV or hepatitis through shared syringes. One way to tackle this problem is to strike down state laws that restrict syringe sales at pharmacies (many national pharmacies chains have this policy in place already). Another alternative is to educate individual pharmacies or companies on the public health consequences of their current practice and to ask them to create a company policy of non-discrimination. Many pharmacies are indeed open to this idea, as they don't want to practice discriminatory policies in their business and increased sales helps their bottom line as well.

Enforcement: Another important aspect of syringe access is police enforcement of drug paraphernalia laws. If officers practice strict enforcement, people who use syringes have a disincentive to seek more, cleaner equipment, and will often re-use or share dirty needles. Additionally, if syringe possession is criminalized, law enforcement are at risk of accidental needle-sticks, as a suspect has no incentive to declare syringe possession to an officer prior to search. According to a San Diego study, one in three police officers will receive an accidental needle-stick with a potentially dirty syringe during their careers, and 28 percent will receive multiple sticks.

Paraphernalia laws can be amended in a number of ways. The first is to pass a law decriminalizing the possession of syringes, effectively removing them from the list of paraphernalia. In a Connecticut study, changes in syringe laws were shown to slash needle-stick injuries to law enforcement by 66 percent. If full decriminalization is not possible, partial decriminalization may be an option, for example, by allowing suspects limited immunity from paraphernalia charges only if they declare syringe possession to an officer prior to search. Or finally, law enforcement can create a policy of non-enforcement, even if state or local law criminalizes syringe possession. South Carolina, in recognition that law enforcement have bigger crimes to go after than possession of needles and spoons, have upheld a policy of non-enforcement for years. Sometimes it's simply a matter of educating officers on how strict enforcement is not always best for the community or for law enforcement safety.

Disposal: The final angle on syringe access to consider is disposal. Syringes pose the greatest hazard to the public after they have been used and potentially contaminated with blood borne pathogens. In states with harsh paraphernalia laws, syringes are often found discarded in public parks, bathrooms, and other areas where anyone could be at risk for an accidental stick. This occurs because if a person is afraid of paraphernalia charges, he or she might dispose of a used syringe immediately after use. States with harsh syringe laws also rarely have adequate disposal methods, such as strategically placed biohazard containers, and even syringes placed in a biohazard container are not immune from criminal charges. To reduce the burden of disease from dirty needles, communities can work to install biohazard containers in strategic places, such as parks, bathrooms, pharmacies, and police departments, as well as to ensure that law enforcement do not arrest for syringes found within approved safety containers.

The country is still sharply divided on syringe exchange; most Northern states embraced the practice long ago and most Southern states have made little to no progress. The West is a mixed bag. But in recent years, with promising break-throughs in HIV and hepatitis C treatment, many see an opportunity to end these epidemics. Small grassroots movements are cropping up in barren states and alliances are forming between North, South and West to fight for more evidence-based public health policies. Over the next few years we may see big changes in disease reduction, especially from the South. It may not involve syringe exchange. But it will involve syringes. And maybe a little barbeque, to add some spice.